Fast Forward Learning

As health care becomes more complex, so does the work of its boards. Trustees must address new payment systems, changes in revenue, mergers, acquisition, new partnerships, new and different market competition, advancing technology and pressures to reduce costs and improve efficiency. Passing on knowledge and general awareness are not enough to keep new trustees from becoming lost in board deliberations about unfamiliar topics that are peppered with unfamiliar acronyms.

Trustees are fully accountable for their decisions and fulfillment of their fiduciary duties beginning with day one of their board term. Yet many will admit it takes at least one, if not two or more years, for most trustees to truly gain the depth of knowledge and understanding needed to be an effective board member. Despite the challenge, many trustees are thrust into board service with insufficient orientation and little or no ongoing governance education. Even organizations with sound orientation programs in place may need to reconsider how to best prepare new trustees for the work and responsibilities of today’s board.

A comprehensive orientation and ongoing board education are essential contributors to each trustee’s ability to fulfill their governance and fiduciary responsibilities to the organization. A new trustee orientation should be an onboarding process that spans a trustee’s first year of board service—a process that, when thoughtfully designed, will speed up the trustee’s depth of understanding, effectiveness and readiness to make valued contributions.


The first step in an effective onboarding process should happen before an individual is asked to accept an invitation to serve on the board. Trustee candidates should receive a written description of board and trustee roles and responsibilities—including a realistic set of expectations—to ensure they have a clear understanding of their responsibilities and the time required to carry out those responsibilities.

Once on board, the trustees should receive an introduction to the organization and a deeper understanding of the board and individual trustees’ roles and responsibilities. This step in the process should take place before the new trustee’s first board meeting, and typically includes the areas outlined below.

A broad overview: An initial orientation session should give new trustees a high-level understanding of the organization, the health care environment and the issues they will be expected to address as board members. The board chair, CEO, CFO, CMO and other hospital leaders should share the responsibility for presenting and discussing key topics, including the overall governance structure and responsibilities, organizational struc- ture, mission, goals and service areas, financial information and key financial indicators and the medical staff and quality of care.

Allowing time for questions and discussion gives leaders direction for subsequent onboarding sessions and governance education, and also promotes collegiality between new trustees and existing leaders.

A tour of the hospital or health system: The CEO and board chair should conduct a tour of the organization with new trustees prior to the trustees’ first board meeting. Where possible, visits should include an introduction to the chief officer or director of each area, with adequate time for a high-level overview of the area. For large health systems with multiple sites, a virtual tour, web meetings and profiles of each site can be useful in giving trustees a “nearly first-hand” introduction.

A “fast facts” summary: Help trustees fast-forward their learning with a one or two-page executive summary of key facts presented in bullet point format.

A governance manual: A manual, whether provided in print or electronically, gives new trustees a valuable resource for information about the organization and the board, and also serves as a reference for all trustees throughout their terms of service. The contents of a comprehensive manual should include:

  • Information about the hospital or health system, including but not limited to, its mission, vision and values, history, facilities description, programs and services, medical staff and foundation
  • Governing documents, including board bylaws, policies and procedures, a statement of fiduciary duties and the conflict of interest disclosure statement
  • Organizational documents, including a copy of the strategic plan, community needs assessment, annual report and Form 990 filing and accreditation reports
  • Financial and quality information
  • A list of board members and executive staff with contact information, board committees and meeting schedules
  • A glossary of acronyms and health care terms

A mentor: Mentors play a key role in welcoming a new trustee to the board. They can be instrumental in advancing a new trustee’s knowledge and understanding of key issues by reviewing agendas prior to board meetings and explaining the significance and nuances of important issues, making time to follow-up after board meetings and introducing new trustees to other board members and executives, drawing them into the board “community” and ensuring their engagement.


Many organizations limit their orientation program to the fundamentals, but as hospitals and health systems integrate, establish new partnerships and continue to transform, there is increasing recognition that boards must advance the experience, expertise and knowledge needed by trustees to successfully govern developing health care systems. Governing boards must be able to make sense of very complex issues, and ask probing, insightful questions. To prepare new trustees for the work ahead, the orientation program should be extended to include more in-depth sessions that address specific educational areas.

The Patient Protection and Affordable Care Act (ACA). Individuals entering trusteeship from outside health care may not realize the transformation the ACA has set in motion. Judging by media and political attention, many believe it’s only about insurance coverage. Before new trustees can fully grasp the issues, opportunities and decisions confronting health care boards, they need to understand the changes brought by the ACA. These include the shift from a fee-for-service payment system to one based on value (cost and quality), payment reforms such as readmissions penalties, bundled payments and Accountable Care Organizations (ACOs), measures of quality and patient satisfaction, continuity of care, community health needs assessments and electronic health records.

Health care trends and forces for change. An awareness and understanding of the trends and forces at work are important factors in strategic assessments, planning and decision-making. These trends and forces will ultimately shape the future of health care. Trustees must understand what is driving health care transformation, the increase in hospital and health system mergers and acquisitions, changes in payment, pressures for transparency, workforce shortages, technology advancements and more.

Quality and patient safety. Gaining an understanding of clinical issues is a particular challenge for laypersons. Yet in a health care system focused on transforming to value-based care, managing population health, enhancing patient safety and delivering the highest quality patient-centered care, it’s imperative that new trustees gain understanding and appreciation for the principles, key performance indicators and critical importance of quality and patient safety.

The market environment and competition. Trustees should review pertinent demographic, market and competitive information—all key factors in fulfilling the board’s mission.

The political environment. New trustees should be informed of key political relationships or concerns with implications for the hospital or health system. The role of politics may vary by state, community and hospital ownership—for example, trustees should know their state’s position on Medicaid expansion, or any political pressure for hospital taxation.


Successful trustee orientation and education programs commit to onboarding new trustees, not just orienting them. The return on investment in developing a comprehensive, written onboarding program is found in the fast-tracked readiness of new trustees as well-informed, contributing and valued board members.

Is Your New Trustee Ready?

While the onboarding process will continue for new trustees, early orientation sessions should prepare them to answer the following questions:

  1. How has the ACA changed health care delivery and spurred health care transformation? What other trends are at work in the health care environment?
  2. What implications do the ACA, market forces and trends have for the hospital or health system?
  3. What are the most critical health needs identified in the hospital or health system’s most recent community health needs assessment? How does the organization’s strategic plan address those needs?
  4. What comprises the organization’s payer mix? Has the payer mix changed since passage of the ACA? How are reimbursement levels impacting the organization’s financial status?
  5. What is the organization’s financial status, including operational margins and margins from its lines of business?
  6. What is the organization’s quality performance? What are the organization’s key quality and patient safety initiatives?
  7. What are the three most critical issues confronting the board in the next year? What are the key initiatives and goals of the organization’s strategic plan? Are these aligned?